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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO xuamuc-eLEc'ra1cAl,
reR IT
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING -MECHANICAL
BUILDING PROJECT IDFNTIFICAT10N
-
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
2,S) FP
OX :S NAMF,: PfION::
1
CONTRACTOR'S NAME.: 2 LIC NQ
P /3
NIC
❑
CONTROLp
ARCHITECHENGIN R: LIC NO:
ADDRESS:
as Z
CONTACT: PHONE:
BUILDING PERMIT INFO
SS
❑ GOnSWldnl Fm Paid by Applicant (Initial)
BLDG ELECT PLUM[{ ECH
El 1:1�M❑
L ENSE CONTRACTOR'S DfiCLARATION
1 hereby affirm Na 1 am licensed under provisions of Chapter 9 (commencing
Q'ry ELECTRIC PERMIT FEE
JOB DESCRIPTION
I'F.RMIT ISSUANCE
whh Sc,tiun9a10)of Dlvlsinn3oflhu Buslnmsuod Profession,G ,nndmyiiieen is
lm full force andoff-.
Ewnsc Cluxx_ ? Lre.M
RESIDENTIAL:
❑SFDWL 0 KI' 1'CHEN REMODEL
❑ADDITION ❑PLUMBING REPIPE
MODIFICATION ❑STRUCTURAL
MODIFICATION
APPLIANCES-NESIUEN9'IAI.
Date _ Commnor
ARCHITECT'SDECI, ANTION
Iunderxtanl myplam,luoll bemedasp Iicrecus
PANELS
UPTO266AMPS
0INTERIOR OCHIMNEY REPAIR
IMPROVEMENT 0SWIMMING POOLS
Licensed Pmfe,innal
201-1000AMPS
DWNEN-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Cammemrx License Law far the
following reason (Section ]0315, Brearesx and Professions Code: Any city or county
pxATI{REMODEIIREPAIk ❑DEMOLITION
❑OTHER
OVER IW6AMI's
SIGNS ELEC'PRICAL
which requires a permit In construct, alter, improve. demolish, or repair any stmeture
SPECIAL CIRCUIT/MISC.
prime to its issuance, also requires We applicant for such potion, to File a signed as¢mem
that he is license) pu mortlo the pno,kme--the Cnn,mcmr's License law(Cbapmr 9
'I EMP METER OR POLE I NST.
COMMERCIAL'
(commencing with Section 7000) of Division 3 of the Business and Processions Calc) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
0 NEW BLDG/ADDITION 0 DEMOLITION
Section ?031.5 by any applicant for o permit subjects the applicant to a civil penalty of
POWER DEVICES
❑TENANT 0FOOD SERVICE
not more min Eve hundred dollors W(W).
0[.as ownerofthc proiwrt, army employees with wagesa their sole compntstame.
will do the work, and the Slmchmc is riot intended oroBend for sale (Sec ]614, Business
IMPROVEMENT
❑OTHER
SWIMMING POOLELECRIG
OUTLETS -SW ITCHES-FIX'I'URIi.
and Professions Cede: The Contractor's License Law dors not apply m at, owner of
NEW RESIDIiNTIA1 ELECTR SQ 1-.
property who builds or improves thereon, and who does xii work himself or through
his ow. cratdoyeas.parochial th I such ininowcoment, are ma intended or uttered for
-le, III i building... p c ld th' n y f completion the
owner -builder isll have the burden f forcing that he did not Wild or improvefor pur-
F -c of ".1c.).
0 1 f thep perryexclusivelycontracting with licensed contractors to
�SQ.IT. FLOOR ARBA.- -•-
r ^
I �
•• LSQ. FT.
1
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construct the prejut(Sce 4(44 Business and Profes Code) The Commcors U.
c se Law does not apply to an owner of property who builds orimprovnthcaon,and
who contractsfor such pn'jeets with a contmemr(s) licensed purmarn to the Convenor's
(�.� CCfI 2'1 1999
( JLr
j
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE19
License law.
❑ I am csempt under Sec. . B & P C fur this reason
1�
ALI'P.R-DRAIN&VENT-WATER EA)nV
Owner Date
VALUATION {
o t
WORKER'S COMPENSATION DECLARATION
BACK FLOW PROTECT. DEVICE
J
' Iherchyaflirm mnderpenol,ynfperjury eneot the Grllowingdeclarations:
I M1twe and will mainmin aCeniGcae of Con<em molt -insure fm Workers Compen-
sation, a pmWdhi for by Section 3]00 ol'the LaMn Coale, Int the performnncc of ,bc
DRAINS-MOOR,ROOPAREA,COND.
STORIES TYPECONS'1'RUCTION
work lint which this pemnil is issued.
FIXTURES - PER TRAP
0 1 have and will maintain Worker's Compensation Insurance, as required by Section
3VIXlofthe Labor Code, for the performance riche work for whkhthispermitisissued
My Workers Compensation Insurance carrier and Policy number see:
Croner: Policy No.:
GAS - EA. SYSTEM- I INC. 4 OUTLETS
OCG GROUP Z4APY7�
I '
GAS - EA. SYSTEM -OVER 4 HIM
GREASMNDUSTRL WASTE INTERCEPTOR
CH RTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
y
BUILDING DIVISION FEES
Into orimmnced mol Memuldecd if,he permit is fninschminreddollarc 14100)
or Icss.)
GREASE TRAP
PLANCHECK FE -E
SEWER -SANITARY -STORM EA. 200 FP.
ENERGY FEE
I certifytha in,he performunceofthe workrovehich this permit is issued. Lshall
no, rind, any per enym mer seas ur beatmre subject the Workers Compen-
an
WATER HEAI'RE WNENTIELECI'R
GRADING FEF:
sation Laws of California. Doc
Afeldwoot
NOTICE TO APPLICANT If, after making this Certificate of Exemption, you should
beronre xuhjca ur the Worker's Conrpensaunn pruvi.tioto, n(,hu Labor Code, you must
WATER SYSTEM TREATINC,
SOILS FEE
WATER SERVICE
forthwith comply with such prm'isions or this permit that W deemed coveted.
CONSTRUCTION LENDING AGENCY
Iherebyulfien ohmmcre is aurnxwetion lcnd,a, agency forme pcdonnonee of
PAID
t Dore Reeelpt a I
f.. L f-_
NEW RESIDENIAL PLMB. SQ. FT.
'. TOTAL:
,he work for which ,his permit is issued (Sec. 3097. Co. C.)
Lender's Name
TOTAL:
Lender's Address
k.
BUILgING F6HL f Z Ie. JQ
1 cattily that 1 have read his application and nate that the above informu,ion is
,
tical.) agree err comply with all city and county ordinances and slate laws relaingm
building construction. and hereby aumorire representatives mf this city to enter upon the
QTY. MECHANICAL PERMIT FEE-
"
SEISMIC FEE
PERMIT ISSUANCEELECTRIC
FEE
_
above-mentioned property for inspection purlmses.
emnity and keep the City of Cupertmo against
(We) agree m save, indharmless
PLUMBING FEE
Iiubillde" adgmcnrs, costs and ripensexwhichm anywm,ocOuc against said City
a. asequence of the griming his p mi,.
ALTERORADDTOMECH,
AIR HANDLING UNIT(TO IO,00( CFM)
MECHANICAL FEE
APPIICA ' UNDEMTAN AN WILI. IMPLY WITH ALI, NON -POINT
sou .EI-GULATIO'S.
AIR HANDLING UNIT (OVER I0,060 CFM)
CONSTRGCTIO'TAX
res
gt antro of Applicao/Contractor Dante
EXHAUST HOLD(W/DUC)
HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100.600 BN)
Will meapplicum or cusum b ddingoccupnnutnre or boodle bnenrdeu.arnmenal
as defined by the Cupc lino Municipal Code. Chapter 9.12, and the Health cad Safety
Calc, Sermon 25532(o!
HEATING UNIT (OVER 100,000 BTU)
O Yes ON.
Will thea Bean, or future Wilding t use equipment or devices which
PP dby the Arco
i, hurardous sir cuntuminonre us ddincd by Om Boy alma Air Quality Management
VEiNILATION HAS ISINGLE RESIDE
PAID
Dote Receip
T
BOILER- COMP(3HP OR 100.00) BTU)
BOILER -COMP (OVER Ialig0 BTU)
nict,
0vc' 0No
AIR CONDITIONER
I have real the hamrdous ma tats requi moons mock halccr 6.95ot the Cnli-
Firmin HealthOwe"ate" Coda Sectio 255115, 533 unJ 25 . 1 understand that if me
ISSUANCE DATE
aaj
NEW RESIDENTIAL MECII SQ. FT.
building IcutrenllY eat an,.,Lai airy rcxpu ility to nutily the mcupant/
y�/)
n the nwhit cox, ",etre s uCenifieaeof Occripase,
ISSUED BY:
TOTAL
ser or umMJ agent Dam
OFFICE